Circulatory collapse after sheath removal in transfemoral transcatheter
aortic valve implantation
Shihoko Iwataa,
Choko Kumea, and Makoto Ozakia
a Department of Anesthesiology, Tokyo Women’s Medical
University Hospital, Tokyo, Japan.
Correspondence to Shihoko Iwata, MD, PhD. Department of Anesthesiology,
Tokyo Women’s Medical University Hospital, 8-1 Kawada-cho, Shinjuku-ku,
Tokyo, Japan, 162-8666
Tel: +81-3-3353-8111; e-mail:shk_wt_0204@ybb.ne.jp
Keywords
transcatheter aortic valve implantation, retroperitoneal hemorrhage,
vascular access-related complication, hemodynamic instability,
perforation
Key Clinical Message
Retroperitoneal hemorrhage is a rare but severe vascular access-related
complication of transfemoral transcatheter aortic valve implantation. In
cases of uncontrollable ongoing bleeding, endovascular treatment or
embolization should be chosen.
Case Presentation
An 87-year-old small woman underwent transfemoral transcatheter aortic
valve implantation (TF-TAVI) uneventfully and was transferred to an
intensive care. However, hemodynamic instability became gradually
obvious, and the abdomen progressively became swollen. Contrast-enhanced
computed tomography revealed free fluid in the retroperitoneal and
intraabdominal cavities, suggestive of retroperitoneal hemorrhage (RPH),
that perforated the abdominal cavity with extravasation of contrast
material (arrow) (Fig. 1a). The injured site of the external iliac
artery (arrow) was confirmed using digital subtraction angiography (Fig.
1b) and repaired with a cover stent.
RPH is a rare but severe
complication of TF-TAVI and has been reported in 0%–2.2% of
cases.1 It is associated with
iliofemoral arterial injuries,
comprising the most frequent vascular access-related
complication,2 of which small vessel dimensions,
calcification, and center experience are the major
predictors.1 The
diagnosis of RPH is often delayed because of nonspecific clinical
presentations such as flank, abdominal, back pain, and/or progressive
hemodynamic instability.1,2 Although the best
management protocol for RPH is still controversial, conservative
management should only be applied in stable patients who require
hemostasis. In cases of uncontrollable ongoing bleeding,
endovascular treatment or
embolization should be chosen. Open surgical intervention is rarely
required.2 If treated inappropriately, the mortality
remains high.2
Conflict of Interest
None declared.
Author Contributions
SI: wrote the initial draft of the manuscript and procured the clinical
images. All the authors, SI, CK, and MO: made a substantial contribution
to the preparation of this manuscript and approved the final version for
submission.
References
Toggweiler S, Leipsic J, Binder RK, et al . Management of
vascular access in transcatheter aortic valve replacement: part 2:
Vascular complications. JACC: Cardiovascular Interventions2013; 6 : 767-776.
Chan YC, Morales JP, Reidy JF, et al . Management of spontaneous
and iatrogenic retroperitoneal haemorrhage: conservative management,
endovascular intervention or open surgery? TheInternational Journal of Clinical Practice 2008; 62 :
1604-1613.